ALOHA!
It's a beautiful snowy day here in Bend. This picture was taken this morning, and although I only had a couple inches of snow at my house, it's still so peaceful and serene to sit and watch the snow falls. It's almost like time stands still and nothing else matters much (except, of course, freeing the world from the tyranny of Endometriosis). I'm getting excited because my brother is coming out in a couple weeks for a ski vacation, and what kind of hostess would I be if I didn't keep him company on the slopes?
The other exciting thing these days is the research that's coming out about the origins of endo. As many of you know, there's a great debate over the mechanisms by which endo forms. The most common explanation is that endometrial cells flow backwards into the abdomen through the fallopian tubes each month during the menses and implant onto surfaces in the pelvis (known as Reflux menstruation, or Sampson's Theory). There are some big problems with this theory, not the least of which it means that endo can never be cured. It also can't explain why endo occurs outside of the peritoneal cavity (such as in the lung, brain, deep in the rectovaginal septum, and even in the prostate gland in men!), why it has been found in girls who haven't yet had a period, or why it follow reliable patterns of distribution regarding its locations in the pelvis. The famous and beautiful Dr. David Redwine has spent his life trying to disprove Sampson's theory in favor of the "celomic metaplasia" theory of formation of endo. Celome is a fancy ten dollar word for the inside of the abdomen, and the theory of metaplasia promotes the idea that certain sites in the abdomen are predisposed to change into endometriosis upon stimulation by certain substances such as hormones (estrogen) or other biologically active molecules. Whether these areas are susceptible because during embryogenesis (formation of organ systems during early gestation before birth) cells of the reproductive tract fall off along the path of migration (everything migrates somewhere in an embryo), or whether they are just naturally susceptible to hormonal stimulation is still unknown. This difference, however, doesn't have as significant an impact on clinical treatment issues as the broader question of metaplasia vs reflux menstruation, because if endometriosis forms every month by falling out of the tubes and into the pelvis, then no surgical treatment short of hysterectomy or tubal ligation will cure endo. On the flip side, if metaplasia is the way endo forms, then once the susceptible tissue has changed into endometriosis (which usually happens by the early 20s), removing it should produce a cure. In fact, when we reoperate on patients who have previously had excision of endo, there is almost never endo on the specific spots in the pelvis that had been previously excised.
So what's the exciting part of this? There's new research showing the earliest transformation of normal ovarian tissue into endometriosis. They actually have pictures showing areas of transition between normal and endometriosis, which substantiates the metaplasia theory. OK, so you're not as excited as I am, but for us humble folk trying to prove to the world that endo can be cured, this is about as exciting as a beautiful snowy day when you're expecting a ski day soon.
Remember, tell your friends ENDO CAN BE CURED! And if they have doctors that tell them, "sorry, there's nothing we can do, just live with your pain", tell them to run the other way and then contact us. It's now not just Dr. Redwine's mission in life, but mine too, to tell the world about what we do, and let them know there's hope for a pain-free life.
Take care, and have a great week.
Dr. Mos

Cocky or Confident?
David said to me last week after reading my blog, "sounds like you're getting a little cocky". I thought about that for a while, and re-read what I had written. I wasn't trying to be cocky or obnoxious or haughty, but to emphasize the point that not a whole lot of people do what we do, and that it is difficult surgery. When I was in the Navy, my last year and a half was spent at Pensacola where the Blue Angels are based. I took care of quite a few of their wives, and while some of the guys were very nice, ordinary guys, a couple were real arrogant, acting like they were some sort of hot shots, quite obnoxious in the way they made everybody feel like they were less important than them, the hot dog fighter pilots. At first I couldn't stand them, but then I realized that being a fighter pilot is a lot like being a surgeon. Both pilots and surgeons have to have a very strong confidence in their own abilities because what we do has life or death consequences. As a surgeon, I have a sacred trust and bond with each patient I operate on. Both of us has to believe and I have to know absolutely that no matter what happens in the operating room I will still be in control. I have to know that regardless of how abnormal the anatomy is, how bad the bleeding is, or what complications I get into, that I will not give up, I will not panic, I will not stop thinking and acting in the best interests of the patient. Because if I do, bad things will happen. This confidence starts small and builds just like it does with anything in life. The more difficult cases I do, the more I build the confidence that, yes, I can do anything I need to; I can remove endometriosis wherever it is. My favorite book when I was a baby was "The Little
Engine That Could". The little train would chug up the mountain and chant "I think I can, I think I can...." until he finally got to the top. Most of the time confidence comes slowly but steadily. Sometimes you back up a few steps when several complications lump together (as they usually do) and you think "what the heck am I doing? Should I be doing this?". Once in a while you figure out something you're doing that's different, but most of the time there's no reason for what happened, and you move on, a little more slowly and carefully for a while until things get back to even keel. Rarely, confidence comes in a big leap, usually after prevailing over a seemingly unconquerable challenge. I remember most of my "giant steps" in confidence, whether in surgery, sports, or relationships. This past two weeks we've done 3 very difficult bowel cases, and I personally did my first laparoscopic bowel resection. I've gotten to be able to see the things that David does, not only the endo lesions, but the anatomy: the small blood vessels hiding beneath the surface, the contours of different structures and their significance. All of a sudden it's all coming together, and what seemed difficult a few months ago is now a whole lot easier (there's still a few more levels to go before it will all be easy, and some surgeries will never be easy, but they will all become possible). I remember the day I learned to trust the edges of my skis. I was at Stevens Pass, WA, on top of this short but really steep outcropping (I think I was 13 or so). I stood there scared to come down because of the steepness, but then I thought about what I knew about how skis worked, and what I had learned in my lessons about weight forward and all that. And all at once I thought "I can do this" and took off down the hill. After about 3 or 4 turns I was down off the steep, and with that one experience I knew that I could ski down anything (maybe not really fast or pretty, but I could make it down). That's how I feel now about my surgical abilities - I may not be as good or as fast as I uptimately will be, but I'm to the point that I can get through anything I face, and I know that (mostly) without a doubt.
Now, having confidence doesn't give you a license to act like you're better than anybody else - actually, it's just the opposite. My confidence in my abilities
hopefully will allow me to act with humility, valuing the relationship I can develop with my patients that allows us to achieve our common goal. What makes me continue this quest to be the best endometriosis surgeon possible isn't the notariety, money or respect. It is the experiences like I had last week, where a scared, traumatized young woman came to us after 3 failed surgeries for endo. She had a difficult lesion that others said couldn't be resected. We took care of her, excising her disease, and when she said good-bye she nearly cried from relief that her 10 year search for resolution of her pain was over, and from joy that she was finally pain free. There is no way to describe the satisfaction, joy, elation, and yes, a little pride, involved in an experience like that. It's like knowing that I'm doing exactly what I was put on earth to do. That's a pretty good feeling.
Take care, and have a great week.

Hello again.
I had the exciting privilege of meeting the one and only Nancy Peterson last week. Nancy is the nurse who started the whole "endometriosis treatment program" here in Bend many years ago. She had endo herself, and because of that, she had a passion for the patients, a special understanding of what they're going through, and I think she stimulated Dr Redwine to continue his quest for conquering the evil disease. Nancy still has a passion for curing endometriosis, and answers quite a few emails every day from women who don't know where to turn. I applaud her efforts to educate and encourage those who are in pain and looking for a better way than is often offered them. Speaking of a better way, we operated on a lady last week who had been to "experts" in several locations around the country in search of someone to rid her of her rectal nodule. One told her it "couldn't be done" because it was in the wrong location, one tried but gave up because "it was too low", and others put her on Lupron (which didn't do anything). We went to war against the forces of evil invading her body, and, at the end of the day (literally), we prevailed, with the villainous nodule in the pathologist's bucket. (do I sound too much like George Bush? I apologize...) It was the largest nodule I've removed, and was quite an exciting surgery. I finally have experienced firsthand the difficulty of this type of surgery, because David makes it look so darn easy, and it's not. Endometriosis is not a disease for the faint of heart, neither for the patient nor physician, but it is incredibly rewarding when you can tell an anxious, fearful patient (fearful because so many others have failed at excising her disease) that she will no longer have the one pain that has ruled her life for the last 10 - 15 years. I think I'm making great strides toward where I need to be in order to continue this work after Dr. Redwine retires. It's exciting and exhausting at the same time, but the joy from taking care of people who need you easily overwhelms the difficulty. March is Endometriosis month, and I encourage you to tell your friends with painful periods, painful sex, or painful bowel movements to get treated, and not give up. I will be doing free record reviews, so if anyone would like me to review their files, contact Kate or Deena in our office.
Take care, and have a great week.
Dr. Mos

Happy New Year!
It's been a while since I last wrote, but I haven't forgotten about you all.
In case you're wondering, I had a great Christmas break, the highlights of which were my brother-in-law and his family coming to visit, and taking my dog cross country skiing. Here's a picture of Birdie.
OK, I should be writing about my quest to become the worlds second best endometriosis surgeon (which I will), but my dog's so cute, I couldn't resist.
So, what of the surgery epic? Things are going well. I've been doing more and more cases, and I'm getting faster, which is good because it means less anesthesia time for the patients. I'm still challenged somewhat by the really difficult cases, where everything is stuck to everything, the anatomy is totally skewed, and it's just plain hard. But, some of the tough cases we do are as difficult as any surgery can be, so it stands to reason that those surgeries won't be easy for anyone. My goal is to do as many surgeries as I can with Dr Redwine before he retires so he can coach me through the difficult ones.
One of the things I would like to do is to visit some of the local endometriosis association chapters and give some community talks, so women with endometriosis know what options are available to them. Many women have multiple surgeries by OB/GYNs who don't know how to recognize the subtler forms of endometriosis, and don't know how or have the surgical skills to treat it appropriately, so they have surgeries which don't result in any significant pain relief. I feel compelled to spread the word that endometriosis can be cured, and that most pelvic pain can be improved quite a bit, but unfortunately the number of physicians who can and will help these women no matter what it takes are few and far between. It's so sad to see patients coming to us after 3,4, 6 previous operations that haven't worked. At least they're finally at the place where doctors will both care about them and care for them appropriately. So, if any of you know contacts with community support groups for women with endometriosis or pelvic pain, please forward their contact info to me. I would be greatly indebted to you, and the women who are suffering without hope will be as well. The most important thing people need when they're going through difficult times is hope, and it's just scary how many patients come to us after being told "there's nothing anybody can do for you". No hope, no possiblities, no compassion.
Well, I'm off to change the world, or at least help a few women along the way. Pay it forward, that's my goal. Peace to you in this new year.

Good Morning everybody,
Today when I woke up it was 9 degrees here in beautiful Central Oregon, and the sunrise on the mountains was spectacular! My mom calls it "strawberry ice cream" on the mts. We are truly blessed here in the Northwest to have such a beautiful place to live and play.
I've been doing quite a few endometriosis surgeries lately and I'm getting faster and more confident. Dr. Redwine is an excellent teacher, and is patient with me as I take a while to dissect the dense scar tissue underneath the endometriosis lesions which lies directly over all the important structures of the pelvic sidewall (the ureter, big blood vessels going to the legs, nerves, the federal reserve bank). Surgery for endometriosis can be tedious, as the surgeon has to be careful to remove all the scarring (fibrosis) from the endometriosis, but leave the ureters, intestines, and blood vessels intact. Most gynecologic surgeons never operate in these areas, and don't know the anatomy of these spaces very well. We've been into the retroperitoneum on every case, and into the spaces behind the vagina, lateral to the rectum, (basically everywhere most surgeons aren't) routinely since I've been here. I finally feel like the rust is coming off after not operating for a while during my move, and I'm back into the swing of things. The cases I used to do well are now incredibly simple, and the cases I used to struggle with I can do now with a little style. If surgery can be compared to baseball, when I was in Hawaii I was a good player in the minor leagues, as are most doctors. Very few play in the major leagues, and David is like Roger Clemons, the star pitcher of the World Series champs. Now I'm getting used to stiffer competition, and am playing (operating) better because of it.
It is always gratifying to see patients happier, in less pain, and more functional after surgery, and I will never tire of being able to help them with their endometriosis pain or their urinary leakage. Life is too short to be miserable, and as doctors we have an ethical mandate not to throw up our hands when difficult problems come at us. We went through years of training so we would be strong, tough, and smart, and to banish the phrase "I'm not comfortable with that...". Here in Bend we see more patients than I care to think about being treated with useless medications and told "there's nothing anyone can do about your pain". We will not quit on anyone, either in the OR or in the office, we will go the last mile to figure out what needs to be done to improve someone's quality of life, to cure their endometriosis, to ease their pain. OK, I sound like I'm on a soap box, but it gets frustrating seeing patients who've been blown off by the people they trusted to help them. I'm incredibly glad I'm here, learning from the best endometriosis surgeon in the world, a guy that doesn't know the meaning of the word "quit".
Have a great week.

Hello again.
I know, I've been negligent and have skipped the blog for a couple weeks. I have a great excuse - the dog ate my homework.....
Seriously, though, a lot has happened in the past few weeks. The most significant event was that we submitted our first paper for publication (well, not Dr. Redwine's first, but our first together). The paper is about the response of endometriosis to either surgical excision (what we do) or to Lupron. The bottom line is that Lupron does not cure endometriosis, and over 60% of those who go on it will have their pain recur within a year. Women who undergo surgical excision, on the other hand, have an 80% chance of NOT having endometriosis 5 years after their surgery. It's a pretty significant difference, and it flies in the face of what the drug reps and many doctors have been telling people (you). One of our missions here in Bend is to stamp out endometriosis any way we can, and since it would be impossible for us to operate on every woman with endo, the next best thing is to educate the world about the best ways to treat it. It's a big job, but somebody's got to do it....
The next most exciting thing involved going to Las Vegas for the AAGL annual meeting (that's the gathering for gynecological laparoscopists from all over the world). David taught several courses, and there was live surgery beamed in from various exotic places (France, Germany, Brazil, Atlanta..). It soon became obvious to me that I was one lucky girl, because Dr. Redwine is a far better surgeon than most of the surgeons being teleported in for viewing. The meeting was informative, and I met quite a few prominent endo surgeons from around the world, so now when I read their papers I can put a name with a face.
The Central Oregon Women's expo took place the weekend I arrived home from Vegas, and Deena and I spent the weekend talking to women about their bad bladders. We had more business than I would have guessed, and spread the word that incontinence can be cured (almost as heretical as curing endometriosis. Go figure). I met quite a few very nice people, did some "networking", as they say, and won an exercise ball, so now I have no excuses for not doing my situps (now called "core exercises").
This week my thoughts are ping-ponging between our next paper and the menu for Thanksgiving dinner. I need a good sweet potato recipe; everything else I've got down pretty well. The other exciting thing that happened last week was a patient told me she actually read my blog! She said it made us more human, and she felt like she knew me. Comments like that make the whole thing worthwhile. I think it will take a while before I learn all of what David can teach me, but I think the surgical aspects will come faster than all the knowledge he has stuffed into his brain. I'm doing more and more, and the main issue is the speed factor. It takes me longer than David to do things, but every case gets a little faster, so there's hope for me. I'm still having fun, and I definitely feel like I'm in the right place. Thanks for reading. More later....

Good Morning!
Winter is on it's way to Central Oregon, as the temp this morning was 16 degrees. Now all we need is some snow in the mountains to start the ski season.
This past week has been an exciting one in our office. We've been refining some of our educational information and will soon be modifying our website so it can better inform potential patients regarding incontinence and pelvic prolapse. There is so much information on this topic, it's hard to know what to include and what would just be contributions to your "cesspool of useless information", so to speak. The trick is how to organize it, and to explain things in ways everyone can understand. Don't worry, it's coming and will soon be better than it is now.
I'm starting to build up my surgical numbers, and last week we repaired a large cystocele (bladder fallen down), and did a laparoscopic sacrocolpopexy. This is a procedure where the top of the vagina is resupported via a piece of mesh sutured to the sacrum (the base of the spine). This procedure has been done for years through a big incision, but over the past few years a few centers have started to perform them through the laparoscope, which allows for a much faster recovery. To my knowledge, we are the only center in Oregon doing these laparoscopic procedures.
I want to let you all know that we will be at the Central Oregon Womens Expo at the fairgrounds in Redmond Nov 11 and 12th. For those of you who live in this area, I'd love to meet you and discuss any issues you may want to talk about regarding womens health, or anything else on your mind. It will be exciting to meet a lot of people (hopefully) and try to address their health concerns.
Take care, and have a great week.
Dr. Mos

Hi there again.
Thanks to those of you who are reading this, and who have written comments. If there's anything you would like me to address, please let me know.
Today Deena, our nurse, brought her 3 legged dog to the office after her bath. It reminded me of Tommy, my cat, and his adventures before we left Hawaii. I was worried that an outside cat who doesn't have front claws and lost his top fang teeth wouldn't fare well here in Bend with the cougars, foxes, wolves, and whatever else is out there lurking. I took him to Mililani (the middle of Oahu) to give him to a family I'd gotten to know there who really wanted a cat. Three days after I left him there, the family called and said Tommy was missing for the last day and a half. A friend of mine and I went up there and spent 3 hours looking for Tommy and calling him, and just as we were ready to give up, I heard him, but I couldn't tell where his howling meow was coming from. Finally, I looked down and realized he was in the storm drain! After rescuing from his wild travails, I couldn't leave him there, so he came to Bend with me. The only thing that wasn't right about taking him back was that the family that wanted him had a little 5 yr old toehead who loved Tommy. So, we went to the pound and found a little 3 month old kitty that looked just like Tommy, and took him up to Kaeden, the little boy. Now, all is well in the feline world, and Tommy's happy being a mostly indoor cat (he doesn't like the cold weather).
I'm currently working on a series of educational talks geared both for women in the community and for physicians. I think there's a great need for better understanding of incontinence and prolapse in both groups, specifically regarding modern treatment options that don't require big huge surgeries. Most primary care docs don't bother asking their patients if they're incontinent because they don't want to deal with it if they are. The other reason is that with only 10 minutes to spend with each patient, they feel it's more important to deal with their high blood pressure and diabetes than with their incontinence, which is understandable to some extent. This is why I'm trying to educate the patients themselves so they can self refer to doctors who like treating these types of problems, and then tell their friends thereby spreading the word that they don't have to suffer in silence. We're going to the Central Oregon Womens Expo at the Redmond Fairgrounds the second weekend in November. Kate and Deena and I will be there to talk with women about incontinence, prolapse, and endometriosis, to try to spread the word that there are some great new procedures that work great with minimal surgery.
Which reminds me, I have to work on my handouts....
See you next week,
Cindy

Here we are again - it's hard to believe it's been a whole week since I last wrote. Two wonderful things happened in the past week - someone actually posted a comment so I know at least 1 person is reading this (thanks!), and more importantly, I did my first case here in Bend. Dr Redwine talked me through my first laparoscopic lymph node dissection. For those of you, probably most, who don't know what this is, it's a procedure only recently adopted by most oncologists for staging cancers of the uterus. You may be thinking, 'well what the heck does this have to do with endometriosis? I don't have cancer.....', and there is an answer to that question. The laparoscopic lymph node dissection is actually the perfect case to learn the deep retroperitoneal pelvic anatomy. This is the part of the pelvis where 99% of general gynecologist never go. It is also where we go quite frequently in the pursuit of invasive endometriosis, and in those cases the anatomy isn't always normal or easy to navigate through, so this was actually a great learning case. More importantly, Dr. Redwine was pleased and impressed with the way we operated together. Plus, I'm showing him a few new tricks that were invented in the 21st century....

The other fun thing I did in the past week was go to Seattle to watch a laparoscopic sacrocolpopexy. This is a procedure done laparoscopically in only a handful of locations around the country, but regardless of the approach (open or laparoscopic) it is the best way to resupport the top of the vagina after it falls down. I've been doing sacrocolpopexies open for many years, and now we will be doing them through the scope, which allows the patient to recover a lot faster than if she has a big incision, as the incision is the part that hurts the most and limits activity the most. A mesh is sutured to the upper vagina, then sutured to the sacrum (the bone at the base of the spine). This procedure gives stronger support and a longer vagina than do most vaginal approaches to apical descent. It also allows better sexual function after the repair, so for most women in their 50s and 60s, it is the ideal surgery for repairing that stubborn nasty prolapse. Sometimes I wake in my sleep and hear vaginas around the world calling "help I've fallen and I can't giddy up....."
But seriously, I'm really excited about how my 2 passions, endometriosis surgery and pelvic prolapse surgery are dovetailing. The joy of helping women return to their normal lives comes from both types of surgery, and the surgical challenges, understanding the anatomy, and doing everything with the most minimally invasive techniques are nothing new to me. Nonetheless, being here and getting to operate with Dr. Redwine is exciting and fulfilling and challenging all at once, and I love it.
Well, I'm off to the hospital for more fun and excitement.
See ya next week, and a hui ho.....

Well, today was a very exciting day, as I got my new toy - a brand new Urodynamics machine. We had 2 pts for the nurses to learn on, and for me to get used to the new machine. It was nice to find out that although this machine is 7 years newer than my old machine, it works very similarly, but better. We can now accurately test for all different types of incontinence, and even detect occult incontinence in women with more severe prolapse, which is a condition where they would leak if it were not for the severe kinking of the urethra which happens when the bladder is falling out. We can also check the strength of the urethra itself, which can indicate just exactly which type of sling should be done, or if a sling is even necessary. Sometimes, especially in the context of a failed prior procedure, a low urethral strength can indicate that a very simple procedure of injecting a bulking agent around the urethra can help resolve the incontinence with essentially no surgery or recovery! Sometimes, though, we find out that the prior procedure has failed, and we gain information from the urodynamics that helps guide the choice of the correct procedure for the patient. Basically, when it comes to incontinence and prolapse, one size does not fit all, so we need all the information we can get to design the right procedure for each individual. The urodynamics also test the emptying phase of the bladder, to ensure that after surgery the patient will still be able to empty her bladder. Believe me, being able to empty your bladder may be something most people never think about, but when you have to go and can't pee, it's MISERABLE!!!!!!
So, off I go to conquer the world of incontinence and put the Depends people out of business....

Well, I'm officially a Bend-ite as my household goods arrived last week. And, my hospital priveleges are official as of tomorrow am, so now I can actually start operating instead of just watching. Of course, when you watch someone whose surgical technique is so different than most (translation - better), you can learn a lot just by watching. Dr. Redwine is actually a very good teacher, and explains his rationale for why he does what he does along with explaining what he's doing. I actually have done quite a few of the surgical techniques in Hawaii that I learned from him last fall when I was visiting Bend. It's difficult and requires skill and perseverence, but it's so rewarding to have patients come back and say their pain is gone after you've removed their endometriosis. I met with some physical therapists today who specialize in womens health and pelvic PT, which is also very important for some women in relieving all of their pain. Sometimes pain starts from a stimulus like endometriosis, or surgical incisions, then muscle spasm sets in, then nerve irritation from the spasm, then more pain, and on and on. When you remove the initial stimulus, ie the endometriosis, in most people the pain goes away, but in those women who have started the cycle with muscle spasm, they continue to have some pain, usually a little different than before their surgery, but still bothersome. That's where the PT comes in. These therapists are experts at finding out exactly which muscles are in spasm, even the deep internal muscles of the pelvis, and then getting them to relax, which usually results in long lasting pain relief of the rest of the pain. I realized firsthand how important this was a few years ago after having my appendix out. I went back to work 3 days after my surgery (typical doctor) and started having terrible muscle spasms of my right side. I tried to fix it on my own, but I was unsuccessful. After a few visits to my trusty PT friend, I was dramatically improved. I strongly believe in a team approach to caring for patients. Whether it's regarding pain management or for incontinence, working with other professionals with a slightly different skill set and a different approach, yet the same ultimate goals, I think gives patients a better outcome, and that's what it's all about.
Well, although the movers came and went last week, I still have a house full of boxes begging to be unpacked, so I better go answer their calls. A Hui Ho...

Aloha,
My name is Cindy Mosbrucker and I'm going to be Dr. Redwine's "clone", as he calls me. I just moved to Bend from Hawaii where I was in private practice for 8 years as an OB/GYN. I've been doing quite a bit of surgery in Hawaii, both for endometriosis as well as for pelvic prolapse and incontinence, but now I'll be able to "learn from the master" and operate with Dr. Redwine on a daily basis. I guess I've been destined to be a surgeon since I was little. When I was in the 3rd grade, Carly Simon's song "You're so vain" was a big hit. My teacher asked us if we knew what it meant, and I raised my hand and said "it's kinda like an artery..." Then when I was in high school, I worked on a ranch and always helped the vet take care of the animals that were injured. We had a sheep with a big abscess ( like a huge zit) on it's back, a horse that ripped the skin off his leg, and various animals who had to get "fixed". I loved being in on the action. I went to Medical school in Chicago at Northwestern, and because it was quite expensive applied for and received a Navy scholarship. My last year of med school I went to Pakistan for 3 months to work at a little mission hospital. What an experience that was - patients would come in extremely sick, and we knew that we had to operate on them even though we didn't know exactly what we'd find, but if we didn't do anything, they would surely die. I'll tell you more stories about this later. I did my residency at Bethesda Naval Hospital, which is where President Reagan was operated on a few times, and had some great experiences there, as well as opportunities for doing a lot of surgery. It helped that I had done quite a few cases in Pakistan, because it gave me more experience than any of the other interns, so I was given more surgeries and more responsibility at an earlier time than most. After residency, I went to Guam for 3 years. It was a nice break from residency where I was working 80 -100 hour weeks. We worked hard and played hard - diving, fishing, golfing, etc. I started doing urogynecology there, where I worked closely with a urologist friend of mine doing complex cases. Then, I moved to Pensacola, Florida, to complete my obligation to the Navy. After a year there, I moved to Hawaii where I was in private practice in Windward Oahu. There I continued my quest to master pelvic reconstruction procedures and curing, or at least improving incontinence in women. As time went on, I refined my procedures to optimize the longevity of the repairs, so that the likelihood of recurrence of the prolapse was less likely. I became the referral gynecologic surgeon for my hospital and although I was still doing some OB, the main focus of my practice was surgical. The biggest reward I get is my patients being so happy after realizing that their small surgery relieved the suffering they'd been enduring from leaking urine, or being uncomfortable from their prolapse. I was happy because I was good at what I did, and could make a difference in the lives of my patients, but I still felt that there was more that I could accomplish. I thought about doing a fellowship in Urogyn, but as I researched this, I realized that I already knew 90% of what I would learn. As I continued my quest to optimize my potential I considered moving from Hawaii, somewhat for family reasons, and partially because I felt that it was time to come closer to home. Then I met Dr. Redwine, and my life changed forever. More later.......